Personal Representative’s Acknowledgment of Attorney’s Compliance with Statutory Limitation on Attorneys’ Fees

U.S. Victims of State Sponsored Terrorism Fund
Personal Representative’s Acknowledgment of Attorney’s
Compliance with Statutory Limitation on Attorneys’ Fees
OMB No. 1123-0013
Expires XX/XX/XXXX

Name of Applicant (Personal Representative)

Claim Number (if available)

Name of Decedent Victim

If the Personal Representative is represented by an attorney for services rendered in connection with
his or her claim submitted to the U.S. Victims of State Sponsored Terrorism Fund, the Personal
Representative must sign and date the following acknowledgement.
I hereby acknowledge that:
Notwithstanding any contract for legal services or retainer agreement, an attorney representing
a Personal Representative Applicant may not charge, receive, or collect, and the Special
Master will not approve, any payment of fees and costs that in the aggregate exceeds 25
percent of any resulting payment made under the Justice for U.S. Victims of State Sponsored
Terrorism Act on such claim. The attorney shall certify his or her compliance with this
section. An attorney who violates this limitation on fees shall be fined under title 18, United
States Code, imprisoned for not more than 1 year, or both.

_____________________________________________________
Signature of Applicant/Personal Representative

_____________________
Date of Signature
(mm/dd/yyyy)